Background
The influence of colonial rule on global health and efforts to unpack is a growing area of concern for global health researchers. In Packard’s history of global health, he outlines how colonial rule and colonial medicine were inextricably entangled, setting the stage for a centralised, western biomedical worldview focused on short-term solutions.1 This same rationale would dictate decision-making and the focus of global health programmes and research even after the end of colonial rule. This culminated in magic bullet solutions, health interventions developed outside of the countries where the health problems exist, and little attention given to supporting the development of basic health services.1 However, as early as 1932, researchers recognised how a more decentralised approach to global health programmes would yield better long-term results.1
Atuire and Rutazibwa describe present day coloniality as a ‘way to engage colonialism in the present and anywhere (internally, bilaterally, globally) as a (re)production of extreme power inequality and the different institutions created to perpetuate this’,2 a description that characterises many sectors of global health today. They go further to describe decolonisation as ‘actively retrieving and cultivating agency in health and healthcare, including unearthing erased and delegitimised health systems’.2 Other contributors to this topic have further described decolonisation of global health as focused on digging out the deep roots of colonial structures and thinking which are not unique to global health in order to move towards an equitable and just world.3–5 Khan et al highlight how an arbitrary choice of interventions in both programmes and academic work or research topics, with little coordination or engagement with people on the receiving end, leads to top-down health programmes that cannot be sustained and perpetuate inequalities in communities.6
March 2020 marked the start of a seismic shift in how global health research, which we believe is intertwined with global health practice, would be carried out for the foreseeable future. In response to the risks posed by the COVID-19 pandemic, governments around the world introduced restrictions on movement, forcing many to adopt a new remote way of working. The pandemic also provided much for practitioners of global health to reflect on, such as which research projects are essential and how we protect those working in the sector. Senior practitioners in the sector outlined opportunities for change in a postpandemic world, with a particular focus on decolonising and decentralising global health as we ‘build back better’.7–9
The potential positive impact of making steps towards decolonising global health have been outlined with much greater vigour since the COVID-19 pandemic began, as this pandemic exposed the imbalances of power and risk that define the field.10 While there is a growing field of literature exploring the implications of COVID-19 for specific areas of research, little is known about how the COVID-19 pandemic has influenced changes in how global health researchers approach their work with respect to values, ways of working and priorities.11 12 One such implication is a departure from rigorous methodology such as in participatory research where methods such as social network analysis, typically done face to face, were done conducted online without a prior assessment of this would affect the results and interaction with participants.11
In response to Abimbola et al and other researchers’ calls to decentralise and decolonise global health, we wish to reflect on how COVID-19 did indeed offer opportunities to alter our practices and to share some ways in which our work during the Wellcome Trust funded POETIC (Provision of Essential Treatment in Critical Care in COVID-19) project allowed us to take further steps towards decolonising our research practices. Our experience as a multinational research team is particularly novel in that we worked across two high-income countries (HICs) (Sweden and the UK) and two lower-income and middle-income countries (LMICs) (Kenya and Tanzania) with strongly contrasting approaches to managing the pandemic.
In this paper, we, as authors, reflect on our experience during the POETIC project outlined in box 1. First, we will discuss how POETIC’s geographically dispersed teams and remote working approach forced us to partially reconfigure traditional power dynamics common in global health partnerships. Second, we will explore ethics in practice for the POETIC project and how the POETIC team navigated the situated ethics questions that emerged. The authors of this paper hope that by sharing our experience, we can further the process of developing a global health sector that is fair and truly representative.
A brief outline of the Provision of Essential Treatment in Critical Care in COVID-19 (POETIC) project and how it was intended to work45–47
POETIC project
The POETIC project is a Wellcome Trust funded ‘collaboration between institutions in Kenya, Tanzania, UK and Sweden to investigate critical care approaches including consensus generation, health economic analysis, health facility assessments, surveys and in-depth interviews of front-line health-workers and stakeholders, with the goal of output relevant to policy and improving critical care’.
The project focuses on investigating critical illness care in various hospitals in Kenya and Tanzania to understand the benefits that might be experienced if essential emergency and critical care was prioritised for all critically ill patients in hospitals in the two countries.